AFR/RC56/15 17 June 2006
REGIONAL COMMITTEE FOR AFRICA ORIGINAL: ENGLISH Fifty-sixth session
Addis Ababa, Ethiopia, 28 August–1 September 2006 Provisional agenda item 8.9
AVIAN INFLUENZA: PREPAREDNESS AND RESPONSE TO THE THREAT OF A PANDEMIC
Report of the Regional Director
EXECUTIVE SUMMARY
1. The Fifty-eighth World Health Assembly and the fifty-fifth session of the WHO Regional Committee for Africa expressed concern about the general lack of preparedness for an influenza pandemic and the need for Member States to draw up and implement national preparedness plans.
2. With the confirmation of avian influenza in some countries of the African Region early this year, the risk of human infection due to the highly pathogenic avian influenza virus H5N1 will persist, as will the threats of occurrence of an influenza pandemic. The occurrence of human cases would create immense new challenges for health systems and social services that are already fragile and overburdened.
3. Preparedness and response in regard to avian influenza and threats of influenza pandemic require concerted action under government leadership with increased urgency and participation of all stakeholders and partners. These priority actions include enhancing national preparedness and response coordination; putting in place adequate financing mechanisms; reducing opportunities for human infection with H5N1; stockpiling antiviral drugs, personal protective equipment and other supplies; and strengthening early warning systems, national health systems and health promotion.
4. The Regional Committee is invited to consider this document and adopt the recommended actions along with the attached resolution.
INTRODUCTION ...1–7 SITUATION ANALYSIS ...8–17 PREPAREDNESS AND RESPONSE...18–29 ROLES AND RESPONSIBILITIES ...30–31 CONCLUSION...…32–33
ANNEXES
Page 1. Bird migratory routes...…6 2. Proposed regional influenza laboratory network ...…6
AFR/RC56/15 Page 1
INTRODUCTION
1. Avian influenza is an infectious disease of birds caused by type A strains of the influenza virus. On rare occasions, these bird viruses can cross over and infect other species, including cats, pigs and humans and can be a potential cause of pandemics. An influenza pandemic occurs when there is emergence of a new subtype that has not previously circulated in humans.
2. Human influenza is transmitted by inhalation of infectious droplets and droplet nuclei, by direct contact or indirectly. So far, the majority of the human H5N1 (haemagluttinin type 5 and neuraminidase subtype 1) infections have been linked to close contact with infected domestic birds during home slaughtering, de-feathering, butchering and preparation for cooking.
3. Three influenza pandemics were recorded in 1918, 1957 and 1968, with the first one resulting in 40–50 million deaths globally. The H5N1 virus was first identified in Hong Kong in 1997 where it infected 18 people and caused six deaths. It re-emerged in Asia in 2003 and has since rapidly spread to other parts of south-east Asia, Eurasia, Europe, the Middle East and Africa. So far, the virus has not acquired the ability to spread effectively among humans.
Nevertheless, the risk of an influenza pandemic is very high.
4. The presence of the H5N1 virus in Africa is of great concern to human and animal health due to several factors requiring urgent action by Member States. These factors include weak health systems and services, the human resources for health crisis, insufficiently developed early warning systems and lack of preparedness to respond to a pandemic.
5. The African Region is highly vulnerable given its inadequate transport and other communication infrastructure, underdeveloped general administration and logistics systems, widespread poverty, and disruption of trade due to the socioeconomic impact of avian influenza.
6. The Fifty-sixth World Health Assembly by Resolution WHA56.19 urged Member States to draw up and implement national preparedness plans and requested the Director-General to continue to provide leadership in pandemic preparedness. The fifty-fifth session of the WHO Regional Committee for Africa held in Maputo, Mozambique, expressed concern about the potential impact of the pandemic in countries of the Region and proposed setting up a technical advisory group. In addition, the Regional Office convened a Regional Meeting on Pandemic Influenza in Brazzaville, Congo and collaborated in holding the Joint UN Meeting on Avian Influenza in Libreville, Gabon.
7. This document updates Member States on the current situation and recommends interventions to further enhance pandemic influenza preparedness and response.
SITUATION ANALYSIS
8. As of mid-June 2006, 54 countries, worldwide, confirmed the presence of H5N1 in domestic and wild birds. The number of humans infected by H5N1 is increasing. By 6 June 2006, the total number of people infected was 225 of which 128 died, representing a case fatality rate of 56%. Since the confirmation of H5N1 in Nigeria, an increasing number of countries in the African Region have confirmed bird infection. The number of outbreaks due to H5N1 globally is on the increase as are the number of human infections.
9. In the African Region, a large number of households keep domestic birds in their backyards. These birds often mingle freely with wild birds that enter households and share outdoor areas where children play. This tends to create opportunities for human exposure. The
widespread practice of home slaughtering of poultry, de-feathering, butchering, and preparation for cooking pose an additional risk.
10. The direct and indirect impact of an influenza pandemic is enormous, affecting health systems, health-care services, political machineries, and other essential services such as public transport, education, police and administration. Economic losses due to culling of domestic birds, and travel and trade restrictions will be considerable.
11. The Regional Office has provided technical support, guidelines and tools to Member States on avian influenza, established an ad hoc panel of experts1 and initiated the Regional Influenza Laboratory Network for diagnosis of human influenza. It has also prepared a Regional Preparedness and Response Plan2 and remains committed to implementing strategies and actions in collaboration with other UN agencies3 and regional economic groupings.
12. As at 7 April 2006, 36 (78%) Member States had confirmed the establishment of a multisectoral avian influenza task force with membership from United Nations agencies. More than two thirds of the Member States have developed national multisectoral preparedness and response plans. About 40% of the countries have had the plan approved by government and shared with development partners for resource mobilization.
13. There are major constraints which demand urgent attention. The constraints include weak health systems with under-budgeted health infrastructure often operating in unhygienic conditions, shortage of skilled human resources prepared to deal with the increased workload, and limited number of well-equipped laboratories in the Region with capacity to confirm avian influenza.
14. The lack of relevant standard operating procedures; weak transport and communication infrastructure; weak general administration and logistics systems; high rate of illiteracy;
widespread poverty; and huge economic losses due to disruption of trade remain the main challenges.
15. The existing antiviral drugs (neuraminidase inhibitors such as oseltamivir and zanamivir) are efficacious if administered within 48 hours after emergence of symptoms. However, increasing the production capacity to meet demand and reducing the high prices to make these drugs accessible in most countries are challenges that need to be met in the short or medium term.
The weak surveillance system leading to late detection of initial clusters of human influenza infection will delay rapid containment and increase the chances of spreading to other foci. Other major challenges are to improve collaboration, cooperation and coordination within and across the various sectors; to update existing health personnel on avian influenza; and to ensure timely sharing of information with all who need to know.
16. Opportunities for effective implementation of an avian influenza plan include political commitment of governments, the possibility of building avian influenza surveillance and response into the Integrated Disease Surveillance and Response (IDSR) framework, the legal basis provided through the International Health Regulations (2005), the possibility of adapting and using the polio surveillance infrastructure, and the improved collaboration between human and veterinary public health services. The availability of effective antiviral drugs and the
1 WHO, Report on a regional ad hoc expert panel meeting, Harare, Zimbabwe, 12-13 October 2005, Brazzaville, World Health Organization, Regional Office for Africa, unpublished.
2 WHO, Regional meeting on pandemic influenza, Brazzaville, Republic of Congo, 12-13 January 2006, Brazzaville, World Health Organization, Regional Office for Africa, unpublished.
3 WHO, Libreville Declaration, Joint UN meeting on avian influenza in Africa, Libreville, Gabon, 20-22 March 2006, Brazzaville, World Health Organization, Regional Office for Africa, unpublished.
AFR/RC56/15 Page 3 technology to develop further influenza vaccines as well as the lessons learnt from affected countries are additional opportunities.
17. A key constraint has been the problem of access to funds for the financing of national and regional preparedness and response plans.
PREPAREDNESS AND RESPONSE
Enhancing national and regional preparedness and response coordination
18. Each country should prepare a consolidated and unified national plan under national interministerial committee leadership. The national committee should be supported by an operational secretariat. Member States should set aside adequate funds which could also be used to compensate farmers. The issue of protein supplementation should also be addressed.
19. The existing intercountry framework for collaboration in, and coordination of, epidemic- prone disease preparedness and response will be used for avian influenza, thus providing timely sharing of information for rapid response.
20. National action plans should clearly identify ongoing activities, available resources and gaps; they should also indicate the resources required for short- and medium-term implementation of planned activities. This will require major investment at national and subnational levels. WHO will work with countries and provide relevant technical support for operationalizing plans, resource mobilization as well as development of evidence-based guidelines, standards and norms to guide implementation using emergency funds.
Reducing opportunities for human infection with H5N1
21. Control of H5NI diseases in animals and prevention of behaviour that exposes humans to the virus will reduce opportunities for human infection and the emergence of an influenza pandemic. Therefore, countries should strengthen surveillance in high-risk areas of trans- boundary migration of animals or wild birds. They should also strengthen surveillance linkages between public health and veterinary laboratories as well as health education and communication targeting communities at risk. The health sector should work closely with its veterinary counterpart to take preventive measures to limit the spread of H5N1 infection among birds.
Strengthening early warning systems
22. Strengthening capacity for timely detection of human cases through enhanced national surveillance and response systems within the framework of IDSR is critical, and it is important to involve communities in surveillance and response. In addition, there is a need to improve the influenza diagnosis capacities of laboratories; enhance laboratory biosecurity levels; and increase collaboration between human and veterinary influenza surveillance laboratories and other networks.
Delaying and containing the spread of influenza at source
23. Accelerated implementation of the International Health Regulations (2005) by Member States will allow the timely notification of human cases of H5N1. Antiviral and other antibiotic drugs to treat secondary infection, personal protection equipment, isolation wards, coherent infection control and use of quarantine are critical in preventing the spread of the disease at country level.
Strengthening national health systems capacity
24. Should there be a pandemic, health-care services could be overwhelmed by the increased workload. In order to minimize the impact, there will be a need to build the capacity of health systems through relevant training of human resources for health and other related sectors in line with a general health emergency preparedness plan for a potential pandemic.
25. The health system should undertake the recommended changes and actions to ensure timely detection and reporting of suspected human cases and appropriate case management. Efforts should be made to ensure availability of and access to recommended reagents as well as specimen referral systems, necessary drugs, disinfectants and personal protective equipment as well as improve the infrastructure for laboratory confirmation and influenza case management.
26. In order to rapidly contain a pandemic at source or slow down its spread through aggressive use of antiviral drugs, WHO has accumulated an international stockpile of antiviral drugs. While it is difficult to satisfy the demand for antiviral drugs such as oseltamivir, it is worthwhile for countries to consider stockpiling them at national or subnational levels. In addition, pre- positioning of personal protection equipment and appropriate laboratory materials and supplies for sampling specimens and transporting them to reference laboratories is necessary.
Implementing a health promotion component
27. The extreme importance of carefully developed and expansive communication and awareness campaigns cannot be over-emphasized, especially to ensure social mobilization and preparedness at community level. Member States should define and implement a health promotion component for strengthening knowledge and skills about transmission, prevention, food preparation and human-bird contact. They should mobilize communities for response and advocate for political support, resource mobilization and policy development.
Developing and enforcing legislation and policy
28. Countries should work with relevant international agencies to develop or update legislation and policies pertaining to health, agriculture, food safety and trade and align them with existing international regulations and standards. The International Health Regulations, for example, safeguard the well-being of citizens of all nations by providing a legal basis for public health actions.
Contributing to influenza research
29. Operations research and other investigations should be undertaken to improve understanding of the epidemiology of avian influenza, including its prevention and control. One of the goals is to ensure that vaccines and antiviral drugs are rapidly and widely available in countries and that there is increased scientific understanding of the virus as time goes on.
Therefore, Member States are encouraged to facilitate the testing of vaccines, medicines and diagnostics. This will create an opportunity for the transfer of technology and for access to scientific knowledge about the disease.
ROLES AND RESPONSIBILITIES
30. Member States should develop and fully implement the national multisectoral preparedness and response plans, taking into account the priority interventions recommended in this document, monitoring and evaluation of implementation of the plans, and timely sharing of information on
AFR/RC56/15 Page 5 influenza in accordance with the International Health Regulations (2005). Member States should establish adequate funding mechanisms with the support of WHO and partners.
31. WHO and partners (e.g. Food and Agriculture Organization of the United Nations and World Organization for Animal Health) should continue to provide countries with guidelines for developing national multisectoral preparedness and response plans and facilitate mobilization of resources to undertake recommended action, including compensating the affected poultry farmers. The WHO Global Outbreak Alert and Response Network will be reactivated to support Member States.
CONCLUSION
32. With the detection of avian influenza in the African continent early this year, the risk of an influenza pandemic will persist. The occurrence of human cases would create enormous new challenges for health systems and services that are already fragile and overburdened. This potentially catastrophic situation requires strong government leadership for finalization and timely implementation of national multisectoral preparedness and response plans. Government response should be within a global partnership that is well coordinated, well resourced with adequate funding and based on the principle of equity.
33. The Regional Committee is invited to consider this document and adopt the recommended actions along with the attached resolution.
ANNEXES
1. Bird migratory routes
National Labs Regional Lab
2. Proposed Flu Laboratory Network
2. Proposed regional influenza laboratory network
